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Common mental disorders in postconflict

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Article in The Lancet July 2003

DOI: 10.1016/S0140-6736(03)13692-6 Source: PubMed

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 RESEARCH LETTERS
Contributors
D Guha-Sapir identified the principal theme and message of the paper,
designed the methods, and wrote the text. W G van Panhuis compiled data,
did statistical calculations, and did the literature search.
Conflict of interest statement
None declared.
Acknowledgments
There was no specific funding source for this study.
1 Paquet C, Van Soest M. Mortality and malnutrition among Rwandan
refugees in Zare. Lancet 1994; 344: 82324.
2 Moore PS, Marfin AA, Quenemoen LE, et al. Mortality rates in
displaced and resident populations of central Somalia during 1992
famine. Lancet 1993; 341: 93538.
3 Shears P, Berry AM, Murphy R, Nabil MA. Epidemiological assessment
of health and nutrition of Ethiopian refugees in emergency camps in
Sudan, 1985. BMJ 1987; 295: 31418.
4 Gessner BD. Mortality rates, causes of death, and health status among
displaced and resident populations of Kabul, Afghanistan. JAMA 1994;
272: 38285.
5 Assefa F, Jabarkhil MZ, Salama P, Spiegel P. Malnutrition and mortality
in Kohistan District, Afghanistan, April 2001. JAMA 2001; 286:
272327.
World Health Organization Collaborating Centre for Research on the
Epidemiology of Disasters (CRED), School of Public Health, Catholic
University of Louvain, 1200 Brussels, Belgium (Prof D Guha-Sapir PhD,
W G van Panhuis MSc)
Correspondence to: Prof Debarati Guha-Sapir
(e-mail: sapir@epid.ucl.ac.be)
Common mental disorders in
postconflict settings
Joop T V M de Jong, Ivan H Komproe, Mark Van Ommeren
Research into postconflict psychiatric sequelae in low-income
countries has been focused largely on symptoms rather than
on full psychiatric diagnostic assessment. We assessed 3048
respondents from postconflict communities in Algeria,
Cambodia, Ethiopia, and Palestine with the aim of establishing
the prevalence of mood disorder, somatoform disorder, post-
traumatic stress disorder (PTSD), and other anxiety disorders.
PTSD and other anxiety disorders were the most frequent
problems. In three countries, PTSD was the most likely disorder
in individuals exposed to violence associated with armed
conflict, but such violence was a common risk factor for various
disorders and comorbidity combinations in different settings.
In three countries, anxiety disorder was reported most in people
who had not been exposed to such violence. Experience of
violence associated with armed conflict was associated with
higher rates of disorder that ranged from a risk ratio of 210
(95% CI 138285) for anxiety in Algeria to 1003 (5261665) 1665); Ethiopia, 34 years (10; 1660); and Palestine, 32
for PTSD in Palestine. Postconflict mental health programmes
should address a range of common disorders beyond PTSD.
Lancet 2003; 361: 212830
Postconflict psychiatric research in low-income countries has
been based largely on non-representative samples and focused
on symptoms rather than on full psychiatric diagnostic
assessment.1 Consequently, data for the prevalence of
diagnosed common mental disorders in postconflict com-
munities is scarce. We did population-based epidemiological
surveys with broad psychiatric diagnostic assessment in
Algeria, Cambodia, Ethiopia, and Palestine. We aimed to
assess the prevalence of common mental disorders in these
four samples and analyse the effect of violence associated with
armed conflict on prevalence and comorbidity rates.
Details of methods, including multistep random sampling
and instrument translation procedures, have been described.2
Participants came from North Africa (Gouvernorat dAlgiers,
2128
For personal use. Only reproduce with permission from The Lancet.
Algeria, periurban area exposed to large massacres, n=653),
southeast Asia (low, modal, and relatively high income
communities in Cambodia, exposed to decades of violence
including autogenocide, n=610), east Africa (Ethiopia,
community of Eritrean refugees living in temporary shelters,
n=1200), and the Middle East (Gaza in Palestine, long-term
refugee population exposed to ongoing violence, assessed
between the first and second Intifada, n=585).
We assessed lifetime mental disorder (Diagnostic and
Statistical Manual of Mental Disorders, fourth edition [DSM-IV])
with the composite international diagnostic interview (CIDI),
version 2.1. We focused on four categories: mood disorder,
somatoform disorder, post-traumatic stress disorder (PTSD),
and (other) anxiety disorder. We defined having a common
disorder as fulfilling criteria for at least one of the four
categories. In our analyses, mood disorder includes dysthymia
and major depressive disorder; somatoform disorder includes
somatisation disorder, conversion disorder, hypochondriasis,
and pain disorder; and anxiety disorder encompasses panic
disorder, agoraphobia, and social and specific phobia. Verbal
rather than written informed consent was obtained because of
illiteracy and fear of signing forms. Ethics approval was
obtained from local programme directors, their boards, and
local authorities.
We classed participants as having experienced violence
associated with armed conflict if they reported experience of
at least one of 17 assessed conflict-related events. We applied
multivariate ANOVA in all groups to test whether general
profiles of disorders and comorbidity differed between those
who had and had not experienced violence. Covariates were
sex, age, marital status, and education; Wilks was the
criterion. We calculated risk ratios for each country to assess
the relation of violent experience with presence of each of the
four categories of disorder. We calculated odds ratios using
multiple logistic regression analyses, adjusting for potential
bias associated with demographic differences. We entered
sex, age, marital status, and education in step one, and
violence associated with armed conflict in step two. Since
odds ratios result in overestimation of relative risk in studies
with frequent outcomes, we converted the adjusted odds
ratios into risk ratios.3 We repeated these regression analyses
to calculate the relation between violent experience and
comorbidity. The pattern of results did not change if
interactions between violence and demographic data were
assessed (interactions were not significant [data not
reported]).
Sociodemographic characteristics varied across groups.2
There were more women than men in groups from all
countries apart from Algeria. Mean ages were: Algeria,
35 years (SD 11; range 1760); Cambodia, 36 years (13;
(12; 1660). Distributions of marital status, number of
children, education, and religion also varied across groups.2
Frequency of exposure to violence differed between
countries (Algeria 92%, Cambodia 81%, Ethiopia 79%,
Palestine 59%; all 2 comparisons between pairs of
samples were significant [p<005]). Within countries, few
sociodemographic differences were associated with violent
experience. In Algeria, Cambodia, and Palestine respondents
exposed to conflict violence were older than those not
exposed (p<005 for all t tests). In Algeria and Palestine,
more men than women reported experiencing violence (all
2 tests p<005). In Cambodia, respondents who had
experienced violence were less educated than non-exposed
people (2 test p=0002).
PTSD and anxiety disorder were the two most frequently
reported problems in all groups (table 1). Among respondents
exposed to violence, PTSD was most frequently reported
(apart from in Cambodia). In respondents not exposed to
THE LANCET Vol 361 June 21, 2003 www.thelancet.com
 RESEARCH LETTERS

n PTSD Mood disorder Anxiety disorder Somatoform disorder Any common disorder
Algeria
Total group 653 374% (337411) 227% (195259) 372% (335409) 83% (62104) 605% (567643)
Without ACAV 53 132% (41223) 151% (55247) 226% (113339) 38% (0089) 396% (264528)
With ACAV 600 395% (356434) 233% (199267) 385% (346424) 87% (64109) 623% (584662)
Risk ratio (95% CI) 314 (180467)* 163 (085276) 210 (138285) 293 (075921) 178 (143206)*
Cambodia
Total group 610 284% (248320) 115% (90140) 400% (361439) 16% (0626) 534% (494574)
Without ACAV 116 69% (23115) 43% (0680) 302% (218386) 17% (0041) 353% (266440)
With ACAV 494 334% (292376) 132% (102162) 423% (389467) 16% (0527) 577% (533621)
Risk ratio (95% CI) 352 (179612)* 178 (069428) 123 (087328) 045 (008257) 141 (106175)
Ethiopia
Total group 1200 158% (137178) 52% (3965) 96% (79113) 27% (1836) 236% (212260)
Without ACAV 256 39% (1563) 08% (0019) 31% (1052) 04% (0012) 78% (45111)
With ACAV 944 190% (165215) 58% (4373) 113% (93133) 33% (2244) 278% (249307)
Risk ratio (95% CI) 453 (248771)* 606 (1512190) 316 (151628) 228 (0>1000) 333 (219478)*
Palestine
Total group 585 178% (147209) 94% (70118) 135% (107163) 53% (3571) 291% (254328)
Without ACAV 238 29% (0850) 29% (0850) 84% (49119) 25% (0545) 126% (84168)
With ACAV 347 280% (233327) 133% (97169) 170% (131209) 72% (4599) 403% (351455)
Risk ratio (95% CI) 1003 (5261665)* 453 (206913)* 258 (158396) 407 (164924) 356 (264453)*
Data are percentage and 95% CI except where indicated. Risk ratios were adjusted for potential bias associated with differences between individuals with and without
ACAV on sex, age, marital status, and education. *p<0001. p=0001. p=002. p=0003. p>01.
Table 1: DSM-IV disorders in people with and without exposure to armed-conflict-associated violence (ACAV)

violence, anxiety disorder was most reported (apart from in
Ethiopia). Somatoform disorders were consistently least
reported. Overall, reported rates were lowest in Ethiopia and
highest in Algeria.
Violent experience was associated with disorder in all groups
(multivariate ANOVA all F tests, p<001). Rates of disorder
tended to be significantly higher in people who had
experienced violence (table 1). The largest risk ratios were for
PTSD, ranging from 1003 in Palestine to 314 in Algeria. For
mood disorder, risk ratios were 606 and 453 in Ethiopia and
Palestine, respectively, and not significant in Algeria and
Cambodia. For anxiety disorder, risk ratio ranged from 210 to
316 in Ethiopia, Algeria, and Palestine and was not significant
in Cambodia. For somatoform disorder, the risk ratio was
significant only in Palestine. The risk ratio for reporting any
common disorder ranged between 14 in Cambodia and 36 in
Palestine.
Comorbidity at 1 year was defined as occurrence of at least
two categories of disorder within a 1-year interval, and was
uncommon in people not exposed to violence. In all settings
apart from Cambodia, in people exposed to violence, the most
frequent comorbidities at 1 year were PTSD with anxiety
disorder and PTSD with mood disorder. Comorbidity of three
disorders was rare, but PTSD with mood disorder and anxiety
disorder was the most frequent combination. No participant
had comorbidity of four disorders at 1 year.
Violent experience was not associated with comorbidity of
two disorders, apart from in Gaza (multivariate ANOVA F test
p=0003). The risk ratio for the association between violence
and 1-year comorbidity of PTSD and mood disorder was
1359 in Palestine, 659 in Algeria, and not significant in
Cambodia or Ethiopia (table 2). The risk ratio for the
association between violence and 1-year comorbidity of PTSD
with anxiety disorder was 1001 and 795 in Ethiopia and
Algeria, respectively, and not significant in Cambodia or
Palestine. With respect to 1-year comorbidities of PTSD with
somatoform disorder and mood disorder with somatoform
disorder, risk ratios were only significant in Palestine (about
nine-fold for both analyses). 1-year comorbidity of mood
disorder with anxiety, 1-year comorbidity of anxiety with
somatoform disorder, and 1-year comorbidity of three
disorders were not related to exposure to violence in any group.
Our results show that common mental disorders are
frequent in areas where most of the worlds survivors of armed
conflict live. Exposure to violence associated with armed
conflict was a potent risk factor for various disorders and
comorbidity in all groups. We have previously reported that in
postconflict settings, PTSD is not only associated with
experience of conflict violence, but also with a range of other
stressors (eg, quality of camps, daily difficulties).2 Therefore,
mental health programmes with a narrow focus on violence
associated with armed conflict or PTSD are probably not
covering the full range of determinants and burden of common
mental disorders in postconflict settings. Postconflict
programmes should address a wide range of problems and
disorders. Our results differ from the 15% PTSD and 55%
depression rates reported in Cambodian refugees living in
camps in Thailand.4 Different measures might account for the
discrepancy. The low rates of mental disorder we noted in
Ethiopia agree with findings of a CIDI survey in the general
Ethiopian population.5 The low rates of DSM-IV somatoform
disorders reported in our study contrast with the high rates of
The International Statistical Classification of Diseases and Related
Health Problems, tenth revision (ICD-10) persistent somatoform
pain disorder reported in Bhutanese refugees.1 CIDI criteria
show that the threshold for somatoform disorder is much
higher for DSM-IV disorders than for ICD-10 persistent
somatoform pain disorder.
There are some limitations to our results. Although we did
random sampling, the selection of catchment areas was not
random.2 Our study is based on the unverified assumption that
DSM-IV disorders have diagnostic validity across cultures.
Data collection involved recall of events and associated
symptoms. Moreover, our groups differed with respect to age
and sex as well as ethnic background. Although we adjusted
for sociodemographic differences, the effects of age and sex on
prevalence might be considerable. Furthermore, although we
used the same methods across sites, we did not control for
cultural differences in response styles. Finally, we did not
assess all common mental disorders. Inclusion of alcohol
dependence, a common disorder in certain cultures, would
have strengthened the study.
Because of our interest in the effect of violence associated
with armed conflict, we split the group into people with and
without exposure to conflict-related events. Although this
approach causes loss of information, it was essential to
generate the prevalence rates of interest. We did not address
whether different events or clusters of events are of equal
weight, which is an important, yet unexplored research topic.
We included a range of common mental disorders and large,
random community samples from understudied populations in
four countries, and our interviewers used uniform full

THE LANCET Vol 361 June 21, 2003 www.thelancet.com 2129

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 RESEARCH LETTERS

Algeria Cambodia Ethiopia Palestine

PTSD mood
Total group 107% (83131) 57% (3975) 18% (1126) 31% (1745)
Without ACAV 19% (0056) 09% (0026) 0% 04% (0012)
With ACAV 115% (89141) 69% (4791) 23% (1333) 49% (2672)
Risk ratio (95% CI) 659 (1012702) 330 (0432151)** 1359 (1807826)*
PTSD anxiety
Total group 126% (101152) 79% (58100) 35% (2545) 29% (1543)
Without ACAV 19% (0056) 17% (0041) 04% (0012) 0%
With ACAV 135% (108162) 93% (67119) 43% (3056) 49% (2672)
Risk ratio (95% CI) 795 (1242983) 325 (0761214)** 1001 (1425850)
PTSD somatoform
Total group 37% (2352) 05% (0011) 08% (0313) 20% (0931)
Without ACAV 0% 0% 0% 04% (0012)
With ACAV 40% (2456) 06% (0013) 11% (0418) 32% (1451)
Risk ratio (95% CI) 907 (1116031)
Mood anxiety
Total group 76% (5696) 69% (4989) 13% (0719) 15% (0525)
Without ACAV 19% (0056) 17% (0041) 0% 04% (0012)
With ACAV 82% (60104) 81% (57105) 17% (0925) 23% (0739)
Risk ratio (95% CI) 441 (0612126)** 251 (057981)** 608 (0714463)||
Mood somatoform
Total group 29% (1642) 05% (0011) 06% (0210) 19% (0830)
Without ACAV 0% 0% 0% 04% (0012)
With ACAV 32% (1846) 06% (0013) 08% (0214) 29% (1147)
Risk ratio (95% CI) 920 (1136077)
Anxiety somatoform
Total group 37% (2352) 08% (0115) 08% (0313) 17% (0728)
Without ACAV 0% 09% (0026) 0% 08% (0019)
With ACAV 40% (2456) 08% (0016) 11% (0418) 23% (0739)
Risk ratio (95% CI) 029 (002399)** 393 (0781811)||
PTSD mood anxiety
Total group 48% (3264) 36% (2151) 08% (0313) 07% (0014)
Without ACAV 0% 0% 0% 0%
With ACAV 52% (3470) 45% (2763) 10% (0416) 12% (0124)
Risk ratio (95% CI)
PTSD mood somatoform
Total group 23% (1235) 02% (0006) 03% (0006) 07% (0014)
Without ACAV 0% 0% 0% 0%
With ACAV 25% (1338) 02% (0006) 04% (0008) 12% (0124)
Risk ratio (95% CI)
PTSD anxiety somatoform
Total group 20% (0931) 03% (0007) 05% (0109) 07% (0014)
Without ACAV 0% 0% 0% 0%
With ACAV 22% (1034) 04% (0010) 06% (0111) 12% (0124)
Risk ratio (95% CI)
Data are percentage and 95% CI except where indicated. Risk ratios were adjusted for potential bias associated with differences between individuals with and without
ACAV on sex, age, marital status, and education. Not all risk ratios could be calculated because some rates of comorbidity were zero. *p=0012. p=002. p=003.
p=004. p=005. ||p=009. **p>01.
Table 2: 1-year comorbid categories of DSM-IV disorder in people with and without experience of armed-conflict-associated
violence (ACAV)

psychiatric diagnostic methods and were familiar with local
contexts. Such research, paired with theoretical investigations
into response styles and transcultural validity issues, could be
used to assess fully the distribution of common mental
disorders in postconflict settings.
Contributors
J T V M de Jong and I H Komproe were responsible for study design,
supervision, data collection, and writing the report. I H Komproe
analysed data. M Van Ommeren contributed to study design and writing
and editing of the report.
Conflict of interest statement
None declared.
Acknowledgments
We acknowledge the large contribution to data collection by local staff in
Algeria (Socit Algerienne de Recherche en Psychologie-TPO:
Mustafa El Masri, Noureddine Khaled), Cambodia (TPO, Cambodia:
Willem van de Put, Daya Somasundaram), Ethiopia (TPO Ethiopia:
Mesfin Araya), and Palestine (Gaza Community Mental Health
Programme: Mustafa El Masri, Samir Quota). This study was supported
by a grant (WW049002) from the Dutch Ministry of Foreign Affairs, the
Hague. The sponsors of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of the report.
1 Van Ommeren M, de Jong JTVM, Sharma B, Komproe I, Thapa S,
Cardea E. Psychiatric disorders among tortured Bhutanese refugees
in Nepal. Arch Gen Psychiatry 2001; 58: 47582.
2 de Jong JTVM, Komproe IH, Van Ommeren M, et al. Lifetime events
and posttraumatic stress disorder in 4 post-conflict settings. JAMA
2001; 286: 55562.
3 Zhang J, Yu KF. Whats the relative risk?: a method of correcting the
odds ratio in cohort studies of common outcomes. JAMA 1998; 280:
169091.
4 Mollica RF, Donelan K, Tor S, et al. The effect of trauma and
confinement on functional health and mental health status of
Cambodians living in Thailand-Cambodia border camps. JAMA
1993; 270: 58186.
5 Kebede D, Alem A. Major mental disorders in Addis Ababa, Ethiopia.
Acta Psychiatr Scand 1999; 100 (suppl): 1829.
Transcultural Psychosocial Organisation (TPO), WHO Collaborating
Centre for Refugees and Ethnic Minorities, Keizersgracht 329,
1016 EE Amsterdam, Netherlands (Prof J T V M de Jong MD,
I H Komproe PhD, M Van Ommeren PhD); and Vrije Universiteit,
Amsterdam (Prof J T V M de Jong, I H Komproe)
Correspondence to: Dr Ivan H Komproe
(e-mail: ikomproe.tpo@pom.nl)

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